Various studies have shown that hospital medication errors occur with alarming frequency, resulting in thousands of deaths and injuries each year. These medication errors most often involve omission of a prescribed drug, dispensing a drug not prescribed or intended, and providing improper dosages or improper administration of a prescribed medication. In one recent wide-ranging study by United States Pharmacopoeia analyzing medication mistakes at community, government, and teaching hospitals nationwide, thirteen percent of the total hospital medication errors involved administering the wrong drug. These types of errors occur in operating rooms, as well as in other hospital locations.
A still common practice in the operating room is to pour drugs into sterile cups. During surgery, the drugs are drawn into syringes for administration to the patient. It is, of course, critical that the correct drug be administered at the correct site, in the correct concentration and at the correct time, during a surgical procedure. For example, during a surgical procedure, Adrenalin may be poured into one cup, for delivery by a first syringe, and Lidocaine may be poured into a second cup for delivery via a second syringe. However, after these drugs are removed from their original containers and poured into the cups, it can be difficult to distinguish between them.
To better avoid administering the incorrect medication or drug, some hospitals have changed procedures by having certain drug vials fitted with caps that allow the medication to be drawn directly into the syringe. Another proposed solution is the use of pre-filled labeled unit doses. While these and other similar techniques can help to prevent giving the wrong drugs to a patient during surgery, disadvantages remain. Initially, these types of procedures have not necessarily been adopted in all hospitals. In addition, these types of procedures can be more difficult and time consuming to carry out, especially while maintaining the sterile field in the OR. These factors discourage using these types of procedures.
Consequently, notwithstanding the vast technical advances made in medicine, there is still a great need to reduce medication errors. This need is especially significant in the operating room (OR) environment.